CDC Guidelines Refuted with Scientific Evidence

Finally, someone is standing up for the truth about opioids and pain patients. These three courageous M.D.s expose the CDC guidelines for the fraud they are.

They’ve written a well-researched paper that refutes the basis of these unscientific and biased guidelines piece by piece with real evidence from scientific studies to back their claims.

I admire these three authors for having the ethics-based courage not to let this gross misinterpretation of science and be accepted without question.

They show how the CDC cherry-picked data with obvious bias (much as they did people). Repeatedly, the CDC interpreted studies with such a slanted view as to assure the outcome they wanted.

When interpreting them without bias, the same studies actually refute the CDC’s arguments.

Recommendations from the Centers for Disease Control and Prevention (CDC) for chronic opioid use, move away from evidence, describing widespread hazards that are not supported by current literature.

These recommendations are in conflict with other independent appraisals of the evidence — or lack thereof — and conflate public health goals with individual medical care

The CDC frames the recommendations as being for primary care clinicians and their individual patients. Yet the threat of addiction largely comes from diverted prescription opioids, not from long-term use with a skilled prescriber in a longitudinal clinical relationship

By not acknowledging the role of diversion — and instead focusing on individuals who report functional and pain benefit for their severe chronic pain — the CDC misses the target.

We provide here a review of the evidence regarding long-term opioid use for chronic pain in order to

a) better point public health efforts, and

b) reduce harm from consequent restriction of these medications for patients who have substantial benefit in their use.

With these new recommendations concerning the use of opioids, the CDC has taken available data and developed a narrative that H.L. Mencken would generally have described as “neat, plausible, and wrong.”

The narrative is as follows:

People in chronic, severe pain are readily provided unproven opioids in ever-increasing doses, get easily addicted and die of overdose either from the opioids prescribed to them or from a switch to lethal heroin.

Neat? Yes. Plausible? Yes. Wrong? Unfortunately, yes.

In addition, the exception “palliative care” is notable.

In defining people to be served by palliative care, the National Consensus Project notes that

“serious or life-threatening illness is assumed to encompass populations of patients at all ages within the broad range of diagnostic categories, living with a persistent or recurring medical condition that adversely affects their daily functioning or will predictably reduce life expectancy.” [7]

Chronic pain, when controlled for sociodemographic factors, has been found to reduce life expectancy by ten years. [8]

It doubles rates of suicidal ideation, attempts, and completion [9]

while quadrupling rates of depression and anxiety. [10]

When people look for some relief of chronic suffering, they are doing so relative to a situation of misery. Given the impact of chronic severe pain, it appears to meet the definition for palliative care itself.

Can people in chronic pain expect meaningful relief from long-term opioid use? Not according to the CDC. The recommendations state there is no evidence for such use and only evidence of harm.

Absence of evidence is not evidence of absence, and the CDC’s claim is also belied by direct reports from patients using long-term opioid treatment who report substantial pain and functional improvements.

The CDC, in telling patients that “the benefits are transient and generally unproven,” [12] is essentially telling patients they are wrong about their pain and function.

When conventional evidence is limited and suffering is high, use of clinical ethics for individual patients has been proposed as a worthwhile decision-making model. [13]

the 2014 National Institutes of Health “Pathways to Prevention Workshop: The Role of Opioids in the Treatment of Chronic Pain” concluded that:

Patients, providers, and advocates all agree that there is a subset of patients for whom opioids are an effective treatment method for their chronic pain, and that limiting or denying access to opioids for these patients can be harmful.

Our consensus was that management of chronic pain should be individualized and should be based on a comprehensive clinical assessment that is conducted with dignity and respect and without value judgments or stigmatization of the patient. [15]

… Biased media reports on opioids also affect patients. Stories that focus on opioid misuse and fatalities related to opioid overdose may increase anxiety and fear among some stable, treated patients that their medications could be tapered or discontinued to “prevent addiction.” [16]

The CDC, in contrast, highlights that prescription opioids are “really dangerous medications which carry the risk of addiction and death.”

Much has been made of opioid-induced hyperalgesia. But even the most recent reviews of this phenomenon are unable to determine its prevalence, and studies have generally been experimental in nature or with unusual administration of opioids (e.g., intrathecal). [22,23]

Whether it is clinically important for patients with chronic pain on standard opioid medication is unclear. [24] As to concern for dose escalation, a recent cohort study found it occurred in fewer than one in ten opioid-naïve patients. [25]

First-line interventions advised by the CDC are limited in their effectiveness

Acetaminophen was recently found to have no impact on osteoarthritis pain. [26]

NSAIDs had their FDA warning strengthened in 2015 regarding heart attacks or strokes [27] and their risks of kidney injury and gastrointestinal bleeding have long been recognized. [28,29]

Anticonvulsants or tricyclic medications for neuropathic pain have a number needed to treat of 5, meaning 4 patients do not have a benefit. [30]

Perhaps “multidisciplinary biopsychosocial care with a prominent component of self-management, generally accepted as the gold standard of care for chronic pain”? According to a pain specialist, its availability has “all but disappeared in the United States.” [31]

the choice to use opioids is not made in a vacuum. The decision is made in comparison with the status quo of chronic, intractable pain despite other medical interventions.

As a comparison, chemotherapy for cancer treatment also has severe side effects, even toxicity. People make the choice to use such treatments because they are choosing against the alternative.

The CDC states that “prescription opioids are just as addictive as heroin.” [32] Others call them “heroin pills.” [33] But a full year after after major surgery, only “0.4% of older opioid-naive patients continued to receive ongoing opioid therapy.”

Unfortunately, recent publications have included “pooled studies with widely differing definitions, outcome variables, and populations,” which detract from their conclusions. [35] Concerns about such misleading data and definitions come from a wide variety of sources. [36–38]

The term “prescription opioids” itself is problematic as the adjective does not distinguish how the drug was actually obtained by the user.

Among those who take opioids long-term for chronic pain, the CDC highlights the potential for overdose (“overdose” is mentioned 144 times in the recommendations) and death

The study cited in the CDC’s own telebriefing [12], however, found “opiate-related” death to occur in 59 of 32,449 (0.2%) patients taking opioids for more than three months. [39] The context of these deaths was unknown

In its review of a Citizen’s Petition to limit doses of chronic opioids, the FDA found that “the scientific literature does not support establishing a maximum recommended daily dose of 100 mg MED [morphine equivalent dose].”[42]

Opioid overdose deaths are generally the result of diverted medications (“diversion” is mentioned 2 times in the recommendations)

heroin, fentanyl, or a combination of these. Diversion is most often from prescriptions for acute, not chronic, pain.[43]

94% of people in treatment for opioid addiction said they chose to use heroin because prescription opioids were “far more expensive and harder to obtain.”

The National Institute on Drug Abuse estimates that fewer than half of young people injecting heroin report abusing prescription opioids beforehand. These crucial details are unacknowledged in the CDC recommendations

Examining this Narrative

Public health interventions are different than clinical interventions.

The former are scaled, diffuse and unilateral.

The latter are individualized and shared.

The CDC recommendations are more focused on public health concerns (such as non-medical use of prescribed drugs) rather than the individual risks and benefits of opioids for actual patients.

The CDC recommendations describe a linear relationship between opioid prescribing and nonmedical use. But data on opioid prescribing [55,56] and nonmedical use [57], state by state, tell a more complicated story

A Different Narrative

Our concern for individual patients is that recommendations and regulatory changes [62] concerning prescribed opioids are increasingly being developed not through evidence, but by a flawed narrative of how addiction develops and overdose occurs. [63,64]

The CDC was provided with descriptions of these flaws in the period of public comment, but chose to make only minor revisions

Our concern for public health is that these recommendations do nothing explicitly to address the major source of prescription opioids used in substance use disorders in the United States: diversion.

The continued use of graphs that track kilograms of prescription opioids and overdose deaths, however, misleads when many of those “prescriptions” are taking place outside of a skilled, longitudinal, patient-clinician relationship. [66,67]

The data we provide here describe a more accurate narrative:

Should other treatments not succeed, people suffering from intractable chronic pain may find that carefully monitored long-term opioids, in combination with other modalities, can help reduce their suffering and improve their function.

The evidence indicates they can do so with a low risk of developing opiate use disorder and an exceedingly low risk of overdose death. As with all treatments, the decision to use and continue long-term opioids should be one of ongoing shared decision-making.

Overall, the new recommendations sacrifice accuracy for a fabricated sense of clarity

But this goal is better addressed by recommendations that consider both individual patient choice and the impact of prescribed opioids on public health through diversion, two very distinct issues.

The outcome might be less neat — yet still plausible — and have the added advantage of being beneficial to the many people struggling with chronic pain

These three individuals are our true heroes.

There are 87 references provided for this article. The authors have done the hard research and now it’s up to us to use this as a tool and spread the message… as much as we with our lives limited by chronic pain and illness, can.

I’ve never asked for anything before, but this is so important I feel justified.

Thank you, my life has been miserable, I have spent most of my time in bed with such pain I can’t get up. How can they say my life would be cut short by opiate use? I have wanted to die rather than suffer with this pain!!!

A THOUSAND TIMES, THANK YOU…Now, can we all DEMAND the same media outlets that threw society, government, doctors, and patients into opioid hysteria air, publish, and post this information with the same fervor!?

One way to spread this accurate information is to use September as national suicide prevention month PR and social media. Share comments about articles and social media about suicide prevention by stating that although prescribed opioid medication isn’t right for everyone who has long term chronic pain that it has been a lifesaver for many and that, just as some CDC staff knew, the new guidelines aren’t based on accurate data and the resulting withholding of effective palliative care for people who suffer from otherwise untreatable chronic pain can and has contributed to suicides.

Funny you should mention that – I wrote an article last year in the National Pain Report that suggested this connection between chronic pain and suicide. This year it’s even more urgent to pair these two, pain and suicide, in the public mind.

This is a very incisive crtique of the CDC guidelines and shows the importance of crittical thinking skills in refuting the CDC guidelines. I have made the point before that the major flaw in guidelines is that they are not focused on the individual but rather what is god for populations. So all guidelines i have seen are either too general or too restricting.
The author make an excellent point about palliative care being more inclusive-and i wonder why the palliative care folks didnt object to the CDC guidelines. But we have seen a great failure of the AAFP ACPS in coming forward to object to the guidelines for the sake of their patients. The AMA, of course was a great supporter of the guidlines-needless to say they arent patient or person focused -and they are the enemies of people in pain. And trust me Id say it to all their faces and deal with their lame responses like Grant took Vicksburg.
But lets not kid ourselves- the guidelines could only have happened due to the lack of organization and energy in the pain community. People in pain individually and collectively are an underclass and treated as peasants whose opinion isnt worth a dime to doctors or to government. Its a tragic commentary on our government and marketplace that they too were so selfishly disempathic that they did their best to drown out any hearing of people in pain. I see some people in pain are waking up to their passivity and the selfish and nihilating furies of providers and their minions in government. Its time for medical consumerism and deliberative democracy-and exodus strategies. Its time the pain community let government and the AMA know we will no longer tolerate being treated as serfs whose rights can only be established by them. Its time to demand a new bundle of rights and let them know we are a social and political force they will have to reckon with. We will no longer be regarded as mindless willess sheepdumb before ur shearers- its time to sheer providers and government. And if people think I am overstating or being an extremist-then you are not ready to see the reality and d what it takes to restore humanity and compassion to our pain care system- or prove me wrong in a public debate. Let us become stronger then the AARP as a political force-failingthat you can expect government, insurers, the AMA and other medical organizations to make the bars thicker in the iron cage they have jailed us in. And golly ihave said theis for 5 years now- and i have been proven right. There has been a continuing escalation of failure in pain care and escalation of committment against the just demands of people in pain. And there will continue to be unless people in pain unite and have a social movement against Big Brothers Brave nEw World of Fascist pain care.

I find it outrageous that they so blatantly skewed their sources – that steps over the line and becomes outright lying. I just hope more people like these courageous doctors (yes, these guys are doctors too) start insisting that our government use facts, not addictonologist PROPaganda to set policy. Yes, I’m a dreamer, but I know I’m not the only one…

I’m trying to keep my hope alive so I can continue tolerating my painful life. If my opioids (which have proven to be the only effective pain relievers for me) are taken away completely, my life will no longer be worth living.

But I’d hate to exit this life without assuring the blame is laid squarely on Kolodny and his propagation of torture for people in pain. I have some interesting fantasies of meeting him…

Like you, I too, am personally outraged buy the fact that the CDC, not only is made up of a completely biased team of ALL anti-opioid physicians & addiction “specialists.” They have intentionally flooded the general public, politicians and news/media outlets with inaccurate statistics, outdated research and half truths cherry picked to suit their needs. Why are they NOT being held ACCOUNTABLE for their blatant lies?? This should NOT be ignored and without consequences. I mean, is this truly WHAT our Government Has Become?

Youre too valuable to the pain cmmmunity to stop your efforts. You’re providing to valuanle a service.
There is always hope and i see with the Kratom petition more people mobilized to reverse governments tyranny against people in pain. I think, just like other social movements- the pain rights mvement is having a slow and rocky start. The irony is- the more tyranny, the more offences against people in pain-the more likely people in pain will be morally shocked into mobilizing and banding together to undo those offenses. And we have great numbers on our side. The key will be nce mobilized will their be a good plan and good leadership/followship. In the past some advocacy groups didnt focus enough on rights=their missions were lacking vision and they mostly created a sense of community.
For yourself you might consider incarvillateine and other herbals that are still legal. There are many plants -50000 believed to be of medicinal value- and pain relief can cme from rue artemesia thunder god vine-and many more, Also you can enhance your bodies endogenous opioid production via omega 3, spinach and dairy.
The key to pain is to keep moving forward and find new ways. Its not east given peoples great attachments but it can be done.

the real bummer is that opioids work so incredibly well for me (in addition to staying active and in shape, eating healthy, and my beginner’s meditation efforts). The main reason I’m so limited is that I’d have to take higher doses than I have been. Were this even possible, I’m not sure I’d want to take much more anyway, especially if I start feeling the negative side effects, like somnolence or dopiness.

I suspect that adding Kratom would have helped me take much lower doses of “less friendly” medicine.

I understand the exasperating situation youve been put in. Though i a not in pain- it distrurbs me greatly the great and often insurmountable difficulties people in pain are forced to deal with.
Incarvillateine is one you may not have tried. And there are other herbs that may benefit you.
I tried kratom 2x- just to see what it does. I was as nauseous as i thought one could be- and the nausea lasted about two hours-but other then extreme nausea- i did not discern an effect from Kratom. Were all different f course-and i have t believe people have gotten pain relief from Kratom.
We all have been forced back onto ourselves to be much more resourceful when it comes to pain care. Market fundamentalism is an awful failure- and i dont really believe it could work anytime soon. And professionals have never cared much abut people in pain in the first place- so we cant expect them to mobilize for a better future. And so its up to people in pain to push the professionals to picking up the pace dramatically and people shuld have an exodus strategy- working closely together to share experience- and maybe get some monies from rich folks or foundations.

I want to say a HUGE THANK-YOU, THANK-YOU, THANK-YOU to these physicians for taking the time to write/research/reference this article. Very little has been brought to light about the devastating effects these guidelines are having on chronic pain patients and how millions are suffering horribly because of it.

I wonder if they’ll suffer professional repercussions from saying what others don’t dare to. I’m disappointed that other doctors aren’t backing them up – publicly and emphatically. I guess most of them don’t have the courage.

I’m glad this article can bring pain patients some hope. But I think the CDC rules are a done deal. Three lonely doctors and one well-researched paper is not going to change any minds at the CDC. Or the FDA. Or the DEA. This isn’t just about chronic pain patients or opioids — it’s about the drug war. And the drug war is even bigger than the war against terrorists.

Perhaps these doctors should’ve written this paper before the rules went into effect. But as they mention, most of this information was given to the CDC and it was ignored.

Seems like adopting the label of “intractable” pain patient might allow us access to opioid therapy in the palliative setting, rather than the label of “chronic.” Pain that lasts 3 months? The pain from my broken foot will probably last 3 months, but it shouldn’t end up being intractable. Neither should it be labeled as chronic.

But how many doctors provide palliative care in the U.S.? Not very many. And they usually deal with terminal patients. How are these doctors going to feel about beginning to treat intractable pain as a palliative condition?

A revolution or a revolt always begins with a few people who refuse to be silenced. This article and others like it may figure centrally in class action lawsuits against the CDC and DEA on grounds of gross fraud and denial of medical care to millions of patients.

Thanks to these 3 doctors. They are real human beings whom took their hypocritical oath in good faith for the betterment of million of legimate chronic pain suffering patients! This inhumame barbaric treatment needs to end. We are #patients not addicts

I’d like to print this and take it to my pain management doctor, but I’m afraid he won’t read it and think I’m drug-seeking. I’ve been with this doc years before my failed back surgery (4 level fusion in 2005) when he used to be able to give me steroid injections for pain. Then, he couldn’t find a spot to inject me, my stenosis was so bad. I opted for surgery in order to get off opioids but the joke was on me. Fast-forward over 10 years and he switches me from morphine tabs to fentanyl patches, which aren’t working so he wants to put me back on the SAME dose of morphine that wasn’t helping. He won’t give me fentanyl tabs because “they’re just for cancer” (so are the patches!). Now, my hip is getting bad, maybe ’cause I can’t walk right (cane assisted since surgery) and I’m feeling helpless. I don’t want to do this anymore and need REAL help but because of the hype now, I don’t dare look for a new doc (all the ones I tried before this one wouldn’t give me more than Tylenol3) in fear of being labeled a drug seeker.

I’m so sorry you’re suffering like this due to the awful misunderstanding about the effectiveness of opioids. Perhaps you could open a discussion with your doctor about how he thinks about opioids.

If you ask him a genuine question with honest interest about what his views are on opioids and how he came to them, you might find an opportunity to correct his wrong perceptions with quotes from the article.

It seems to me that you have to show a doctor you want to know and understand his viewpoint (fear of losing his livelihood if he prescribes) before you can present your own opinions (and documentation). I think doctors currently feel attacked by the government/society if they prescribe opioids and attacked by pain patients if they don’t, so if you can calm their fear of attack they might be able to listen better. Going so far as to verbally assure them you can understand their fears of the DEA and CDC might help get past their defensiveness.

I know this is much easier said than done and may not be applicable in your situation, but those are my thoughts and what has worked for me in the past.

When I (luckily still) get my refills, I always ask my doctor if she is feeling pressure from anyone about it and if my prescription is “getting her into trouble”, and complimenting her for being brave enough to push back against this new prohibition for me. I hope this makes her feel like the hero she is to me.

I am writing a keynote address for the Washington Rally Against Pain on October 22nd, based on this excellent article. Several other patients and a couple of doctors are also on the program. Our meme for the event is “Stop The War Against Pain Patients!” I encourage all who read this article to tweet a link to it, with that meme and the hashtag #patientsnotaddicts or one of the chronic pain membership addresses.

“Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.” – Margaret Mead
There are those in society that suffer denialism and some who suffer from fatalism. Both are dead ends. In 2008 after seeing someone i cared about suffer from poor pain care i decided to do something about it-and in less then a year i got legsilation int nys to require education in pain care- and now it is a reality-though in a less rigorour form. As is plain to see i have poor writing skills- but i wrote anyway to many legislatrs in ny= i even chided congressman engel into legislation on palliative care education. And so i say this to offer hope. One doesnt have to be the most eloquent or articulate- to make a difference. As somene wrote- showing up is half the battle. The Kratom advocates showed up-they are winning the battle and i dont see how the DEA can make kratom schedule 1 anymore. Now, of course the opioid issue is far more difficult then the kratom issue. But i believe if enough people show up, so to speak the government will relent. We have right on our side, and we are amassing evidence of the great suffering current opioid policies are causing. And worse then that our fudnamental rights and freedom are at stake- we cannot afford to lose the opioid battle.
So i hope enough Americans will realize the opiid guidelines are a great threat to our democracy and individualism and will not allow denialism or fatalism to prevent them from heeding the words of Margaret Mead.

Do not discount the benefits of acceptance, which is different than being in denial or feeling fatalistic. After all, how many enemies can one person fight against? My main enemy is pain. All this other stuff is just background noise.

I think we’ve already lost the opioid war. You believe differently. I accept and respect your position. Maybe you could see it within yourself to accept mine.

I think people in pain has been subject to a variety of invalidating and demotivating forces that make it less likely for them to speak out. In an official sense being in chrnic pain is not very socially accepetable- to people nt suffering pain its like talking at length that a part of you is dead. So people who are not in pain dont wont to really hear about others pain. Medicine, of course has been suspicious and invalidating of pain for centuries. And pain itslef can be demotivating. Fatalism sets in for too many people in pain and they become socially and or politically inert when it comes to their pain.
There are of curse others that defy their pain in one or more ways. I think you defy yur pain and instead it making you inert you to some extent have made your pain inert.

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